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Pelvic prolapse student



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  • 1. Pelvic Floor Dysfunction Khalid Sait FRCSC Professor ( Gynecological Oncology) Faculty of Medicine King Abdulaziz University
  • 2. Normal Pelvic Anatomy
  • 3. Pelvic anatomy n  Ligament: connect two bone n  Tendon: connect bone to muscle n  Mesentery: fold of peritoneum contain vessels, nerve and lymphatic n  Fascia: connective tissue surround two muscles n  Pelvic bone: fixed landmark
  • 4. Pelvic floor Support n  Passive Support: Pelvic Bone Endo pelvic fascia n  Active Support: Pelvic muscle
  • 5. Endopelvic fascia n  Uterosacral ligament n  Pubocervical fascia n  Rectovaginal fascia n  Urogenital diaphragm
  • 6. Pubocervical fascia n  Extend between the two isch spine at level of cervical ring and laterally inserted at the white line which is the arcus tendenus
  • 7. Rectovaginal fascia n  Extend between the two isch spine at level of cervical ring and laterally inserted at the white line which is the arcus tendenus
  • 8. Uterosacral ligament n  From S1and S4 to the back of cervix at level of cervical ring
  • 9. White Line arcus tendenus n  Is condensation of fascia at the lavator ani muscaly that extend from isch spine to the back of sympesis pubis at the level of pubic tubercal n  Its detachment cause paravaginal defect
  • 10. Urogenital diaphragm n  Condensation of the fascia of: n  Ischiocavernosus n  Bulbocavernosus n  Deep transverse pernieal muscle
  • 11. Pelvic floor Muscle n  Levator ani muscle 1- Pubovisceral muscle Hammock muscle ( u shape muscle) sling like arrangement Include puboccygeous and puborectalis 2- Iliococcygeous muscle Triangle muscle n  Coccygeus
  • 12. Pelvic support n  Not important in pelvic support: Urogenital diaphragm Superficial perineal muscle Bulbocavernosus muscle Round ligament Broad ligament
  • 13. DeLancey levels of vaginal support n  Level I suspension: uterus and vagina vault utrerosacral n  loss of this support result in vaginal and uterine prolapse n  Level II: attachment bladder and rectum pubocervical and rectovaginal fascia) (loss of this support result in cystocele and rectocele n  Level III Fusion diffuse to perineal body
  • 14. Pelvic Organ Prolapse (POP) Protrusion of the pelvic organs into, or out of, the vaginal canal
  • 15. Pelvic Organ Prolapse (POP) n  Central/Apical: Uterine /Vault Prolapse n  Anterior: Cystocele / Urethrocele n  Posterior: Rectocele/Enterocele
  • 16. Pubo-cervical fascial defect Richardson
  • 17. Uterine prolapse n  First degree: descend below ischial spine not reach introits n  Second degree : cervix visible at introits n  Third degree: procidentia the whole uterus is out side the introits
  • 18. Tetralogy of “Fall-out”
  • 19. Assessment Bump 1998
  • 20. Epidemiology of POP n  Life time risk of developing POP: 11.1% n  13% of hysterectomies in all ages n  Most common reason for hysterectomy in women > 50 Olsen 1997, Allard 1991
  • 21. Epidemiology of POP Post-hysterectomy vault prolapse (PHVP): n  11.6%: hysterectomy for pelvic prolapse n  1.8%: hysterectomy for other benign disease Marchionni 1999
  • 22. Etiology & Contributing Factors
  • 23. Etiology & Contributing Factors n  Childbirth n  Congenital weakness of fibro muscular support ( white > black) n  Aging / Estrogen deficiency n  Increased intra-abdominal pressure n  Repetitive pelvic pressure (Lifting or Coughing) n  Neurological disease (eg. Spina bifida) n  Connective tissue ( eg. Ehlers-Danlos syndrome)
  • 24. Damage to pelvic support n  Neuromuscular damage n  Connective tissue damage
  • 25. Symptoms and Signs n  A symptomatic n  Heaviness / full feeling in the pelvis n  Some thing coming down n  Lump in vagina n  Urinary symptoms( up to anuria) n  Difficult in defection n  Difficulty in walking n  Vaginal discharge and bleeding n  Dysparonia ( the muscle are slack) n  Vagina flatus ( whoopee cushion)
  • 26. Management of POP
  • 27. Management n  Treat underlying cause n  Conservative: Kegal /Passaries n  Surgical
  • 28. Kegal Exercise n  Find the right muscle: Lavator ani muscle (Hammock muscle/Triangle muscle) 1- stop the flow of urine 2- stop passing gas 3- squeezes your finger in vagina n  How frequent you do n  Repeat but don't overdo it
  • 29. 1.  Obliterative (colpocleisis) 2.  Reconstructive Ø  Abdominal/laparoscopic: o  Para-vaginal repair Ø  Vaginal: o  Anterior colporrhaphy o  Graft interposition o  Para-vaginal repair Ant. POP: Surgical management
  • 30. Anterior colporrhaphy: Procedure
  • 31. Paravaginal repair: Procedure
  • 32. 1.  Obliterative (colpocleisis) 2.  Reconstructive (vaginal): n  Posterior colporrhaphy (+/- perineorrhaphy) n  Graft interposition n  Site-specific repair Post POP: Surgical management
  • 33. 1.  Obliterative (colpocleisis) 2.  Reconstructive Ø  Abdominal/laparoscopic n  Colpo-sacropexy n  Uterosacral suspension Ø  Vaginal: o  Sacro-spinous vault suspension o  Iliococcygeus suspension o  Mayo/McCall culdoplasty Apical POP: Surgical Management
  • 34. Principal of repair
  • 36. Lefort